ORIGINAL ARTICLE
Bali Medical Journal (Bali Med J) 2016, Volume 5, Number 2: 15-19
Published by DiscoverSys
1
Social Determinants of Health
Research Center, Alborz University
of Medical Sciences, Karaj, Iran
2
Faculty of Nursing & Midwifery,
Alborz University of Medical
Sciences, Karaj, Iran
*
Correspondence to: Mahnaz
Akbari-Kamrani, Faculty of Nursing
& Midwifery, Alborz University of
Medical Sciences, Karaj, Iran
dr.akbarikamrani@abzums.ac.ir
Open access: www.balimedicaljournal.org and ojs.unud.ac.id/index.php/bmj
The relationship between body image coping
strategy and eating disorders among iranian
adolescent girls
Malihe Farid1 & Mahnaz Akbari-Kamrani2*
ABSTRACT
Background: Due to physical and psychological changes during
puberty, most common problem of young people is body image defined
as degree of size, shape and general appearance. Wrong perception
of body image and dissatisfaction with body image in people can
lead to eating disorders and stress. Peace of mind is in fact a mental
mechanism that people use it to reduce physical and emotional strains
coping with stressful situations. The aim of this study was to determine
the type of coping strategy of adolescent girls and its relationship with
their eating disorders.
Methods: This is study is a cross-sectional study in which 573 female
adolescent of Karaj participated. Two-Stage Random Sampling was
used in this study. In this study, to assess people who are at risk of
eating disorder, the nutritional approach assessment questionnaire of
EAT-26 was used, while Strategy Inventory Body Image Coping-BICSI
questionnaire was used to determine the type of coping strategy.
Results: In this study, the mean age of participantswas16.6 (±1/62)
(19-14 years). In this study, 23.7% of participants had an eating
Keywords: Adolescent girls, BMI, body image coping strategies, eating disorders
Cite this Article: Kamrani, M., Farid, M. 2016. The Relationship between Body Image Coping Strategy and Eating Disorders among Iranian
Adolescent Girls. Bali Medical Journal 5(1), 15-19. DOI: 10.15562/bmj.v5i1.151
INTRODUCTION
The transition from childhood into adolescence is
one of the most important stages of life.1 In such
a course of evolution, there are changes occurring
in body posture, thinking and social communica-
tion. In their biological, psychological and social
development, children are involved in a series
of changes, including a desire to gain indepen-
dence, pursuing models outside the family and the
need for approval and acceptance from others.2
Adolescents, particularly females, tend to pay
special attention to their weight and body shape
during puberty due to various reasons includ-
ing cultural, social, racial factors.3 The problem
of teenagers mostly concerns their body image,
because people in this period experience physi-
cal and psychological changes, where increasing
height, weight and emergence of secondary char-
acters in a short time can alter the individual’s
self-image.4 Self-image covers beliefs, conscious
P-ISSN.2089-1180, E-ISSN.2302-2914
CrossMark
disorder. Mental image of an individual of his body had significant
correlation with eating disorder (P= 0.000). Kruskal-Wallis test showed
a significant relationship between the type of coping strategy adopted
by adolescent girls and eating disorder score of them (P= 0.007). The
relationship between coping strategy and body image and having or
not having the eating disorder was determined by Chi-square test at
the borderline level (P= 0.054).
Conclusion: In this study, results showed that there is relationship
between coping strategy of adolescent girls and the eating disorder
score of adolescent girls. The highest score was assigned to getting
involved with body image, followed by avoidance and rational
acceptance. Since the use of inappropriate coping strategies is
associated with negative results such as eating disorders and
depression, it is expected that eating disorders resulting from mental
body image to be reduced by management of people in using correct
and appropriate coping strategies.
and unconscious feelings about the body.5 Body
image is a mental visualization that one has of
physical appearance. In other words, it revolves
around the positive and negative feelings about
the size and shape of body.6 Although body image
is multi- dimensional structure, it is often defined
as a degree of physical appearance, size, shape and
general appearance.7 Negative body image can
lead to body dissatisfaction, feeling of being unat-
tractive, and finally haunted by thoughts about part
of the body to the extent of dysfunction.8 Moreover,
wrong perception of body image can lead to physi-
cal and emotional problems.9
Body image dissatisfaction in people leads to
stress. Peace of mind is a mechanism employed
by a person to reduce physical, mental and
emotional strain in dealing with stressful situa-
tions. In connection with controlling body image
dissatisfaction and challenges, there are three
15
ORIGINAL ARTICLE
strategies outlined as follow: Avoidance Coping
Strategy, which includes individual efforts to
evade thoughts and feelings that threaten physical
image (like not standing in front of the mirror),
Appearance Fixing Coping that includes attempts
to hide or modify individual body composition so
as to fix the defects or threats, and Positive Rational
Acceptance Coping which includes mental activity
and behavior focusing on positive self-care (such
as when there are other advantages dominant on
body composition).10
During adolescence, weight is a determinant of
attractiveness. Poor body image or dissatisfaction
with body size and weight can increase the likeli-
hood of health-risky behaviors such as poor diet
and in sufficient in take of food.11 In many cases,
teenagers report body dissatisfaction along with
concern about weight gain and weight loss behav-
iors including eating less,exercising for weight
loss. For several years, emphasis has been shifted
on weight loss and diets around the world, and all
social classes and ethnic minorities are significantly
facing the prevalence of eating disorders.12
One of the groups at risk of eating disorders
involves females 14-25 years of age.13 In adoles-
cents, eating disorder has been described as the
most common disease after obesity and asthma.14
The overall prevalence of eating disorder in adoles-
cents and young students is 4% specifically for
anorexia nervosa. It is 0.5 to 1% among adolescent
girls and young women, while it is 1 to 3% for
anorexianervosa.15
Several studies have examined the prevalence of
eating disorders among adolescents and their body
image. Eating disorders forms in adolescence and
continues to develop throughout young ages. Given
that inappropriate treatment of such diseases would
lead to serious complications and consequences for
the individual, it is crucial to explore the issue of
preventing and resolving the underlying causes of
such disorders16 so as to be applied by health plan-
ners and policy-makers.
Coping strategies are one way of adaptation with
body image. Studies have shown that Avoidance
Coping Strategy and Appearance Fixing Coping can
curtail the individual’s stress, but they are accom-
panied with eating disorders. Positive Rational
Acceptance Coping can be an ideal for prevention
of eating disorders.
The present study was designed, since there are
insufficient studies in Iran examining the strate-
gies adopted by young people facing challenges of
body image. This study attempted to determine the
type of coping strategy adopted by Iranian adoles-
cents and its relationship with eating disorder.
It is hoped this information can help the health
16 Published by DiscoverSys | Bali Med J 2016; 5 (2): 15-19 | doi: 10.15562/bmj.v5i1.151
managers and education system to develop strat-
egies for prevention of these disorders in Iranian
vulnerable population. The researchers hope that
the results in the next step will design eating
disorder prevention programs in accordance with
coping strategy.
METHODS
This cross-sectional study involved the target
population of high-schools girls in Karaj. The
sampling was two-stage random, where the first
stage involved selection of high-school girls from
four areas of education Karaj based on a sample and
population size. In fact, the samples were selected
from one or two schools through a simple random
procedure. In each school, samples were obtained
from tenth, eleventh and twelfth grades.
To estimate the frequency of people at risk of
eating disorders, the nutrition and attitude assess-
ment questionnaire (Eating Attitude Test- 26) also
known as EAT-26 (Garner and Garfinkel, 1979)
and demographic questionnaire were used. EAT-26
questionnaire is a screening tool for people prone
to eating disorders, the validity and reliability of
which have been confirmed by epidemiological
studies in different countries including Iran). In
Iran, the questionnaire was translated and validated
by Dejkam et al. (2000). The questionnaire contains
26 items related to attitude, habits and feeding
behavior, where the maximum score is 78. The 11
items of questionnaire measure the nutrition atti-
tude while 15 items are related to diet performance.
The responses in EAT-26 are scored on a Likert
scale: always (3 points), most of the time (2 points),
very often (1 point) and three additional options
include sometimes, rarely or never (0 points).
A  score equal to 20 or greater is defined as risk for
eating disorders.
In this study, the type of coping strategy against
body image was determine through standard tools
of Strategy Inventory Body Image Coping (BICSI).
The questionnaire included 29 items relying on
three strategies of Avoidance, Appearance Fixing
and Positive Rational Acceptance.
Avoidance strategies is assessed through 8 items
based on 4-point Likert scale (Α≡0.74 Cash, Santos,
et al., 2005). Appearance Fixing contained 10 items
based on a 4-point Likert scale (Α≡0.9 Cash, Santos,
et al., 2005). Finally, Positive Rational Acceptance
contained 11 items (Α≡0.85 Cash, Santos, et  al.,
2005).
The decisive questions of any strategy were
scored based on the Likert scale throughout several
options including disagree, strongly disagree, no
comment, agree, strongly agree. Then, the total
 ORIGINAL ARTICLE

scores of each subject in any type of strategy was The Kruskal Wallis test indicated a significant
calculated and compared against one another. Any relationship between the type of strategy adopted
strategy scored the highest by a subject would be by the students and the scores of eating disorder
considered dominant at p=0.007. Moreover, the Mann-Whitney test
The validity and reliability of BICSI standard indicated this difference between the groups with
questionnaire were determined through a study appearance fixing coping and positive rational
cross-sectional as standardization tool. acceptance coping strategies (p=0.000). Finally,
there was a difference between groups involved
avoidance coping and appearance fixing coping of
DATA ANALYSIS
body image strategies (p=0.05) (Table 1).
After collecting the information, all the vari- The Chi-square test did not reveal any signif-
ables were investigated to specify the relationship icant relationship between the type of strategies
between the dependent variable (eating disorders), adopted by students and, birth order, weight, being
through Chi-square, ANOVA, T-Test and logistic first child in the family or not, education level, field
regression. of study, age group and having older sisters or not.
The Kruskal-Wallis test did not reveal any signifi-
cant relationship between the strategies adopted by
RESULTS
students and their age.
A total of 573 adolescent girls participated in this The Chi-square test indicated a significant rela-
study. The average age of the participants was tionship between the type of strategy adopted by
16.16±1.26 years old (from 14 to 19 year sold). the students and engagement of their parents in
the medical community. In fact, positive rational
Table 1.  Summary of Eating disorders and Type of coping strategy acceptance tended to be adopted by children of
Eating disorder medical practitioners.
In this study, 23.7% of participants had an eating
Mean±SD Test P-value
Type of disorder. The relationship between body image
coping strategy coping strategy and having an eating disorder
Appearance fixing body image 10.9 ± 14.81 was based on EAT-26 questionnaire (P=0.054).
Positive rational acceptance 8.5 ± 11.73 Kruskal-Wallis 0.007 Moreover, the Pearson correlation was twice as
Avoidance 12.50 ± 11.04 much at 5.834. Such relationship was not applied to
different education levels of study.
The relationship between being suspected to have
eating disorder based on the EAT-26 questionnaire
Table 2.  Eating disorders and distributions of BMI
and BMI was significant. Moreover, being suspected
Eating disorder to have eating disorder was more likely among those
Positive Negative
BMI who were overweight (P=0.013) with the Pearson
correlation equal to 10.76. The individual body
Lower than natural weight 5.1% 7.6% image had a significant relationship with eating
Natural 62.5% 72.8% disorder, which tended to be higher in subjects
Overweight 21.3% 14.3% with obesity and overweight images. Moreover, the
Obese 11% 5.3% Pearson correlation was equal to 66.73 (Table 2).
The average weight of subjects with normal body
mass index was 54.3 kg and the average ideal body
weight was 52.5 kg. Moreover, nearly 60.8 percent
Table 3.  Body mass index and Individual body image
of subjects with normal body mass index tended to
Based on body mass index Individual body image reduce their weight (Table 3).
(percentage) Frequency (percentage) Frequency
Obese 38(6.6) (8.4)48
DISCUSSION
Overweight 91(15.9) (22.1)126
Natural 401(70) (55.8)318 Body image coping is a strategy employed by
individuals to manage their thoughts and feelings
Lower than natural 40(7) (13.7)78
in the face of challenges to their body image. The
weight
results of this study showed that there is a correla-
Total (100.0)570 (100.0)570 tion between the strategy adopted by students and
Lost data 3 3 eating disorder. The highest score was assigned
Total 573 573 fixing body image, avoidance and rational accep-
tance strategies, respectively

Published by DiscoverSys | Bali Med J 2016; 5 (2): 15-19 | doi: 10.15562/bmj.v5i1.151 17

ORIGINAL ARTICLE
The results of study by Cash (2005) and
Melnyk (2004) similarly indicated that two strat-
egies of fixing and avoidance were employed
for frequently by the subjects dealing with body
image.10,17 The results of study by Cash (2005)
suggested a significant association between the
adoption of avoidance strategies and fixing with
lower self-esteem.10
In the current study, the relationship between
body image coping strategy and eating disorders on
the basis EAT-26 questionnaire was on the border
line. In their study, Callaghan et al. (2007) found a
significant correlation between avoidance strategies
(r=0.61, p<0.01) and fixing body image (r=0.49,
p <0.01) and dissatisfaction with body image (18).
In the study by Cash (2005), subject with higher
avoidance strategies against body image tended to
have higher dissatisfaction.10
The Chi-square test indicated a significant rela-
tionship between the type of strategy adopted by
the students and engagement of wither parents in
the medical community. In fact, rational acceptance
tended to be adopted by children of medical practi-
tioners. In a study by Mackenzie (2012), there was
a significant correlation between gender, education
and awareness in adoption of coping strategies
against body image.19
In a study by Cash et al. (2005), there was a
significant relationship between higher body mass
index and adoption of avoidance strategy and fixing
against body image.10 In this study, 60.8 percent of
subjects with normal body mass tended to reduce
their weight. Some studies conducted in Western
countries indicated that 80% of 18-year-old girls with
normal weight and height had a desire to lose weight
and show abnormal eating behaviors.8 Various stud-
ies have highlighted the effect of several factors such
as age, gender, race, socio-cultural factors, social
class, depression, anxiety and self-esteem.20,21
Furthermore, there was no significant correla-
tion between the type of strategy adopted by
students and the weights, birth of first child, as well
as level of education, profession, age group and
having an older sister.
In multiple studies in different countries, the
prevalence of patients at risk for eating disorders
varies. Saudi Arabia: 24.6%; Oman: 29.4%; UAE:
23.4%20 South Africa: 8.6%;22 Brazil: 16.76%;23
United States: 26%; Canada: 16%, UK: 4.92%;24
Italy: 15.8%.25 In this study, 23.7% of participants
had an eating disorder. Moreover, there was a
significant relationship between body image and
eating disorder. In patients with obesity and over-
weight body image, eating disorders tended to be
significantly higher.
18 Published by DiscoverSys | Bali Med J 2016; 5 (2): 15-19 | doi: 10.15562/bmj.v5i1.151
CONCLUSION
Women usually face more stressful challenges for
body image as compared to men. Coping strategy
can be a vital mechanism to reduce pressure in
stressful situations and harmony with the envi-
ronment. In achieving adaptation, people employ
different mechanisms, each bringing about different
results. Adoption of poor coping strategies will give
rise to negative outcomes such as eating disorders
associated with depression. It is recommended that
appropriate grounds be provided to train young
people to be familiar with a variety of strategies and
how to manage them. It is expected that manage-
ment can help individuals adopt the correct coping
strategy so as to curtail psychological and eating
disorders due to false body image.
ACKNOWLEDGMENT
This study was funded by grant through Alborz
University of Medical Sciences, Karaj, Iran.
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